www.ndcgaf.org

Loan Application Checklist

Grow America Fund (GAF) is a national Community Development Financial Institution focused on providing flexible and patient expansion loans to healthy and growing small businesses, manufacturers and distributors. GAF is an approved SBA 7(a) PLP lender and follows appropriate SBA lending practices.

WHAT DO I NEED TO SUBMIT IN ORDER TO BE CONSIDERED FOR A LOAN?

In order to properly review your loan request, please submit the following items:

1. Attached Loan Intake form.

2. 2011, 2012 and 2013 Federal Tax Returns (please provide entire copy) for primary businessapplicant, and any other affiliated companies.Note: If the business has not yet filed 2013 tax returns, submit 2010, 2011 and 2012 returns,along with year-end statements for 2013.

3. 2014 interim financial statements not older than 60 days, including:a. Income Statement and Balance Sheetb. A/R Aging reportc. A/P Aging report

(Please ensure all reports cover consistent time frames.)

4. Current debt schedule (template attached)

5. Completed SBA and GAF forms (attached) SBA Form 413 – Personal Financial Statement for any principal with 20% or greater

ownership SBA Form 912 – Statement of Personal History for every principal with 20% or greater

ownership Completed GAF credit release form

6. Information relating to the project (ie: construction proposals, equipment estimates, etc.)

You may reach out with questions, or submit these items via:

Email: Mobile:

Address:

Jborges@nationaldevelopmentcouncil.org (718) 578-5804 (M)(212) 682-1106 (O)Jose R. Borges, Grow America Fund Loan Officer 708 Third Ave, Suite 710New York, NY 10017

Phone:

Grow America Fund, 21 E. Canon Perdido St, Suite 212A Santa Barbara, CA 93101 Tel: (805) 698-8005 Fax: (805) 456-3879 

Small Business Loan Intake Form

The Grow America Fund (GAF) is a national Community Development Financial Institution focused on providing flexible and patient expansion loans to healthy and growing small businesses, manufacturers, and distributors. GAF is an approved SBA 7(a) PLP lender and follows appropriate SBA lending practices.

Applicant Information

Name: Phone: U.S. Citizen? □ Yes □ No

Business Legal Name: DBA:

Business Street Address:

City: State: Zip:

Email: Website:

Business Characteristics

Industry: □ Manufacturer □ Distributor □ Retail □ Services □ Food/Restaurant □ Other ___________________

Entity Type: □ C-Corp □ S-Corp □ LLC □ Partnership □ Sole Proprietorship □ Nonprofit □ Other __________

Brief Description of Business:

Year Business Est. (e.g. 2005): Owner (Optional): □ Minority □ Woman □ Veteran □ Living with Disabled

Previous Years Gross Revenue: $ YTD Revenue: $ ___ Months

Net Income: $ Current Full Time Employees: Projected Employees:

Credit and Loan Information

Use of Funds Amounts Loan Amount Requested: $

Real Property Acquisition $ Equity Contribution: $

Leasehold Improvements $ Credit Score:

Machinery & Equipment $ Current Bank Relationship:

Working Capital $

Other_______________ $ Comments (Optional):

TOTAL $

Referral Source (Name, Organization): Date:

As of Date:

Creditor Name Current Balance

Original Loan

Amount

Average Monthly Payment

Month/ Year

InitiatedTerm Interest

Rate Collateral How funds were used?

Grow America Fund, 21 E. Canon Perdido St, Suite 212A Santa Barbara, CA 93101 Tel: (805) 698-8005 Fax: (805) 456-3879

Note: Include ALL business debt including (but not limited to): term loans, lines of credit, tax liens, landlord payments, franchise payments, subordinated officer debt, etc.

Debt Schedule

Business Name:

Credit Release Form

I/We hereby request and authorize you to release to Grow America Fund, Inc. and/or the National Development Council for verification purposes, personal and corporate credit reports and information concerning the company/corporation/partnership and/or the officers and individuals listed below. That information may include but is not limited to:

a. Employment history dates, title, income, hours worked, ect.b. Banking (checking and saving) accounts of recordc. Mortgage loan rating (opening date, high credit, payment amount, loan balance, and payments)d. Any information deemed necessary in connection with a consumer credit report for my loan application

This information is for the confidential use of this lender, Grow America Fund, Inc. (GAF) in compiling a loan report. A photographic or carbon copy of this authorization (being a photographic or carbon copy of the signature(s) of the undersigned), may be deemed to be the equivalent of the original and may be used as a duplicate original.

Date:

Application Information Business Name:

Phone Number:

Affiliated Business:

Phone Number:

Individual 1 Name of Officer/Owner:

Address for last two Years:

Social Security #: Date of Birth:

Signature: X

Individual 2 Name of Officer/Owner:

Address for last two Years:

Social Security #: Date of Birth:

Signature: X

Individual 3 Name of Officer/Owner:

Address for last two Years:

Social Security #: Date of Birth:

Signature: X

Grow America Fund, 21 E. Canon Perdido St, Suite 212A Santa Barbara, CA 93101 Tel: (805) 698-8005 Fax: (805) 456-3879

Yes No

Home Telephone No. (Include Area Code):

Business Telephone No. (Include Area Code):

5. U.S. Citizen?

Yes No

Yes No

Yes No (If yes, indicate date parole or probation is to expire.)

Most recent prior address (omit if over 10 years ago):

From:

To:

Address:

Present residence address:

From:

To:

Address:

2. Give the percentage of ownership or stock owned or to be owned in the small business or the development Company

Signature

OMB APPROVAL NO.3245-0178Expiration Date: 2/28/2013

Please Read Carefully : SBA uses Form 912 as one part of itsassessment of program eligibility. Please reference SBA Regulations andStandard Operating Procedures if you have any questions about who mustsubmit this form and where to submit it. For further information, please callSBA's Answer Desk at 1-800-U-ASK-SBA (1-800-827-5722), or check SBA'swebsite at

Name and Address of Applicant (Firm Name)(Street, City, State, and ZIP Code) SBA District/Disaster Area Office

Amount Applied for (when applicable) File No. (if known)

Name and Address of participating lender or surety co. (when applicable and known)

United States of America

SMALL BUSINESS ADMINISTRATION

STATEMENT OF PERSONAL HISTORY

Personal Statement of: (State name in full, if no middle name, state (NMN), or ifinitialonly, indicate initial.) List all former names used, and dates each name wasused. Use separate sheet if necessary.

First

3. Date of Birth (Month, day, and year)

4. Place of Birth: (City & State or Foreign Country)

Social Security No.

If non-U.S. citizen, provide alien registration number:

6.

PLEASE SEE REVERSE SIDE FOR EXPLANATION REGARDING DISCLOSURE OF INFORMATION AND THE USES OF SUCH INFORMATION.

IF YOU ANSWER "YES" TO 7, 8, OR 9, FURNISH DETAILS ON A SEPARATE SHEET. INCLUDE DATES, LOCATION, FINES, SENTENCES, WHETHERMISDEMEANOR OR FELONY, DATES OF PAROLE/PROBATION, UNPAID FINES OR PENALTIES, NAME(S) UNDER WHICH CHARGED, AND ANYOTHER PERTINENT INFORMATION. AN ARREST OR CONVICTION RECORD WILL NOT NECESSARILY DISQUALIFY YOU; HOWEVER, UNTRUTHFUL ANSWER WILL CAUSE YOUR APPLICATION TO BE DENIED AND SUBJECT YOU TO OTHER PENALTIES AS NOTED BELOW.

YOU MUST INITIAL YOUR RESPONSES TO QUESTIONS 5,7,8 AND 9.

7. Are you presently under indictment, on parole or probation?

8. Have you been charged with and or arrested for any criminal offense other than a minor motor vehicle violation? Include offenses which

have been dismissed, discharged, or not prosecuted (All arrests and charges must be disclosed and explained on an attached sheet.)

9. Have you been convicted, placed on pretrial diversion, or placed on any form of probation, including adjudication withheld pending probation, for any criminal offense other than a minor vehicle violation?

10. I authorize the Small Business Administration Office of Inspector General to request criminal record information about me from criminal justice

agencies for the purpose of determining my eligibility for programs authorized by the Small Business Act, and the Small Business Investment Act.

Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil penalties, and a denial of your loan, surety bond, or other program participation. A false statement is punishable under 18 USC 1001 AND 3571 by imprisonment of not more than five years and/or a fine of up to $250,000; under 15 USC 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if submitted to a Federally insured institution, under 18 USC 1014 byimprisonment of not more than thirty years and/or a fine of not more than $1,000,000.

Agency Use Only

SBA 912 (1-10) SOP 5010.4 Previous Edition Obsolete This form was electronically produced by PCFS 2000.

Please Note: The estimated burden for completing this form is 15 minutes per response. You are not required to respond to any collection of information unless it displays a currently valid OMB

approval number. Comments on the burden should be sent to U.S. Small Business Administration, Chief, AIB, 409 3rd St. S.W., Washington, D.C. 20416 and Desk Officer for the Small Business

Administration, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C. 20503. OMB Approval 3245-0178.

11. Fingerprints Waived

Fingerprints Required

Date Sent to OIG _________

Date Approving Authority

Date Approving Authority

Date Approving Authority

Date Approving Authority

12. Cleared for Processing

13. Request a Character Evaluation

Title Date

(Required whenever 7,8 or 9 are answered "yes" even if cleared for processing)

If No, are you a LawfulPermanent resident alien:

Middle Last

Yes No

1.

ever

ever

CAUTION - PENALTIES FOR FALSE STATEMENTS:

INITIALS:

PLEASE DO NOT SEND FORMS TO OMB

INITIALS:

INITIALS:

INITIALS:

www.sba.gov.

This form was electronically produced by PCFS 2000.

PERSONAL FINANCIAL STATEMENT

OMB APPROVAL NO. 3245 -0188 EXPIRATION DATE: 09/30/2014

U.S. SMALL BUSINESS ADMINISTRATION As of ____________________

Complete this form for: (I) each proprietor; (2) general partner; (3) managing member of a limited liability company (LLC); (4) each owner of 20% or more of the equity of the Applicant (including the assets of the owner's spouse and any minor children); and (5) any person providing a guaranty on the loan. Return completed form to : 7(a) loans - to the lender processing the SBA application; 504 loans - to the Certified Development Company processing the SBA application; Disaster loans - to the Disaster Processing and Disbursement Center at 14925 Kingsport Road, Fort Worth, TX 76155 -2243; and 8(a)/ BD applicants who are individuals claiming social and economic disadvantaged status and their spouses - electronically at http://www.sba.gov or send hard copy with paper application to either of the two following offices:

8(a) BD only

Mail to the following address, if your firm is located in one of the states below:

Mail to the following address, if your firm is located in one of the states below:

US Small Business Administration DPCE Central Office Duty Station Parkview Towers 1150 First Avenue 10th Floor, Suite 1001 King of Prussia, PA 19406

Small Business Administration Division of Program Certification and Eligibility 455 Market Street, 6th Floor San Francisco, CA 94105

MA, ME, NH, CT, VT, RI, NY, PR (Puerto Rico), VI (US Virgin Islands), NJ, PA, MD, VA, WV, DC, D E, GA, AL, NC, SC, MS, FL, KY, TN

IL, OH, MI, IN, MN, WI, TX, NM, AR, LA, OK, MO, IA

Name Business Phone

Residence Address Residence Phone

City, State, & Zip Code

Business Name of Applicant/Borrower

ASSETS (Omit Cents) LIABILITIES (Omit Cents)

Cash on hand & in Banks ………………………….... ... $ ________________ Accounts Payable ……………………………………….. $ _______________ Savings Accounts …………………………………...... .. $ ________________ Notes Payable to Banks and Others ………………….. $ _______________ IRA or Other Retirement Account ………………… …. $ ________________ (Describe in Section 2)

(Describe in Section 5) Installment Account (Auto) ……………………………… $ _______________ Accounts & Notes Receivable ……………………… … $ ________________ Mo. Payments $ _____________

(Describe in Section 5) Installment Account (Other) …………………………….. $ _______________ Life Insurance -Cash Surrender Value Only ……… … $ ________________ Mo. Payments $ _____________

(Complete Section 8) Loan on Life Insurance ………………………………….. $ _______________ Stocks and Bonds …………………………………… … $ ________________ Mortgages on Real Estate ……………………………… $ _______________

(Describe in Section 3) (Describe in Section 4)

Real Estate ……………………………………………... $ ________________ Unpaid Taxes …………………………………………….. $ _______________ (Describe in Section 4) (Describe in Section 6)

Automobiles - Total Present Value ………………... ... $ ________________ Other Liabilities …………………………………………… $ _______________ (Describe in Section 5, and include (Describe in Section 7)

Year/Make/Model) Total Liabilities ……………………………………………. $ _______________ Other Personal Property …………………………… …. $ ________________

(Describe in Section 5) Net Worth …………………………………………………. $ _______________ Other Assets …………………………………………… . $ ________________

(Describe in Section 5)

Total $ ________________ Total $ _______________

Section 1. Source of Income Contingent Liabilities

Salary ……………………………………………………. $ ________________ As Endorser or Co -Maker ………………………………. $ _______________

Net Investment Income ………………………………... $ ________________ Legal Claims & Judgments ……………………………… $ _______________

Real Estate Income …………………………………….. $ ________________ Provision for Federal Income Tax ……………………… $ _______________

Other Income (Describe below)* ……………………… $ ________________ Other Special Debt ………………………………………. $ _______________

Description of Other Income in Section 1.

*Alimony or child support payments need not be disclosed in "Other Income" unless it is desired to have such payments counted toward total income.

SBA Form 413 (08 -11) Previous Editions Obsolete 1

This form was electronically produced by PCFS 2000.

Section 2. Notes Payable to Banks and Others. (Use attachments if necessary. Each attachment must be identified as a part of this statement and signed.)

Name and Address of Noteholder(s) Original Balance

Current Balance

Payment Amount

Frequency (monthly, etc.)

How Secured or Endors ed Type of Collateral

Section 3. Stocks and Bonds. (Use attachments if necessary. Each attachment must be identified as a part of this statement an d signed).

Number of Shares Name of Securities Cost Market Value

Quotation/Exchange Date of

Quotation/Exchange Total Value

Section 4. Real Estate Owned. (List each parcel separately. Use attachment if necessary. Each attachment must be identified as a part of this statement and signed.)

Property A Property B Property C Type of Real Estate (e.g. Primary Residence, Other Residence, Rental Property, Land, etc.)

Address

Date Purchased

Original Cost

Present Market Value

Name & Address of Mortgage Holder

Mortgage Account Number

Mortgage Balance

Amount of Payment per Month/Year

Status of Mortgage

Section 5. Other Personal Property and Other Assets. (Describe, and if any is pledged as security, state name and address of lien holder, amount of lien, terms of payment and if delinquent, describe delinquency)

Section 6. Unpaid Taxes. (Describe in detail, as to type, to whom payable, when due, amount, and to what property, if any, a tax lien attaches.)

Section 7. Other Liabilities. (Describe in detail.)

MM

SBA Form 413 (08-11) Previous Editions Obsolete 2

/

/ /

This form was electronically produced by PCFS 2000.

Section 8. Life Insurance Held. (Give face amount and cash surrender value of policies - name of insurance company and beneficiaries)

I authorize SBA/Lender to make inquiries as necessary to verify the accuracy of the statements made and to determine my creditworthiness. CERTIFICATION: (to be completed by each person submitting the information requested on this form) By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting information submitted with this form is true and complete to the best of my knowledge. I understand that SBA or its participating Lenders, or Certi fied Development Companies will rely on this information when making decisions regarding an application for a loan from SBA or an SBA Participating Lender, or for participation in the SBA 8(a) Business Development (BD) program.

Signature _________________________________________________ Date ______________________

Print Name _________________________________________________ Social Security No. ______________________

Signature _________________________________________________ Date ______________________

Print Name _________________________________________________ Social Security No. ______________________

NOTICE TO LOAN APPLICANTS: CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Knowingly making a false statement on this form is a violation of Federal law and could result in criminal prosecution, significant civil penalties, and a denial of your loan. A false statement is punishable under 18 U.S.C. §§ 1001 and 3571 by imprisonment of not more than five y ears and/or a fine of up to $250,000; under 15 U.S.C. § 645 by imprisonment of not more than two years and/or a fine of not more than $5,000; and, if subm itted to a Federally insured institution, a false statement is punishable under 18 U.S.C. § 1014 by imprisonment of not more than 3 0 years and/or a fine of not more than $1,000,000. NOTICE TO APPLICANTS OR PARTICIPANTS IN THE 8(a) BD PROGRAM : CRIMINAL PENALTIES AND ADMINISTRATIVE REMEDIES FOR FALSE STATEMENTS: Any person who misrepresents a business concern's status as an 8(a) Progr am participant or SDB concern, or makes any other false statement in order to influence the 8(a) certification or other review process in any way (e.g., annual review, eligibility review), shall be: ( 1) Subject to fines and imprisonment of up to 5 years, o r both, as stated in Title 18 U.S.C. § 1001; (2) subject to fines of up to $500,000 or imprisonment of up to 10 years, or bot h, as stated in Title 15 U.S.C. § 645; (3) Subject to civil and administrative remedies, including suspension and debarment; and (4 ) Ineligible for participation in programs conducted under the authority of the Small Business Act.

PLEASE NOTE: The estimated average burden hours for the completion of this form is 1.5 hours per response. If you have questions or commen ts concerning this estimate or any other aspect of this information, please contact Chief, Administrative Branch, U.S. Small Business Administration, Washington, D.C. 20416, and Clearance Officer, Paper Reduction Project (3245 -0188), Office of Management and Budget, Washington, D.C. 20503. PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 413 (08-11) Previous Editions Obsolete 3 3